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SC WCS > Anaesthesiology SC003: The Patient Is Very Ill After The Operation: Post-operative Management > Flashcards

Anaesthesiology SC003: The Patient Is Very Ill After The Operation: Post-operative Management Flashcards

1
Q

Complications of early post-anaesthesia

A

Immediate danger: ABC
1. Airway problems

  1. Breathing
    - Hypoventilation
    - Hypoxia
  2. Circulatory problems
    - Hypo / Hypertension
    - Arrhythmias

Non life-threatening:

  1. Neurological
    - Confusion
    - Over-sedation
    - Stroke
  2. Others
    - Pain
    - N+V
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2
Q

Aim of post-anaesthesia

A
  1. Ensure patient safety
  2. Prioritise —> ABC
  3. Treat other common problems to enhance patient comfort
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3
Q

Post-anaesthetic Care Unit (PACU)

A

Patients stay here ~30 mins after surgery

On arrival:

Check:

  1. Airway patency
  2. Breathing + Oxygenation (e.g. TV)
  3. Vital signs: BP, HR, Temp

Give:
- ***~30-40% O2 (2-3L via nasal cannula) for GA patients (ability to oxygenate themselves ↓ after GA even in healthy individuals)

Monitor:

  1. Pulse oximeter
  2. Non-invasive BP
  3. RR
  4. Fluid input + output (urine, drains)

Manage:
- Other problems i.e. Pain

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4
Q

Patient evaluation for Post-op problem

A
  1. History
    - Story from patient (chief complaint / HPI)
    —> but patient may not be fully conscious / may not know what happened during the operation
    - **Pre-operative assessment
    - **    Anaesthetic record (e.g. drug used)
    - ***Surgical record (e.g. blood loss)
  2. P/E
    - e.g. look for Tension pneumothorax
  3. Investigations
    - Blood tests (e.g. POC tests: electrolytes, ABG, Hb, BG)
    - Imaging
    - Other monitoring devices (e.g. ECG)
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5
Q

General approaches to early post-op problems

A
  • ***Simultaneous assessment + supportive treatment
  • Airway + Breathing + Circulation
  • Treat the patient but NOT the monitors
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6
Q

***Airway obstruction

A

Causes:

  1. ***Tongue falling back (∵ pharyngeal, airway muscles relax + supine position, esp. obese / OSA patients)
  2. ***Laryngospasm (Vocal cord spasm, partial / complete obstruction, more common in paediatric)
  3. ***Secretions (e.g. sputum, may also induce Laryngospasm)
  4. Vomitus
  5. Blood
  6. External pressure on trachea (e.g. haematoma in neck surgery)
  7. Foreign body (e.g. gauze packing)

Signs:

  1. Partial obstruction
    - ***Noisy respiration
  2. Total obstruction
    - **Cessation of airflow at mouth (put hand over oral cavity to feel)
    - **    No breath sounds
    - No chest expansion

—> ***Clinical observation rather than looking at SaO2!!! (Do NOT wait till oxygen desaturation, ∵ will be already apneic for a while + sigmoid O2 dissociation curve: once start to drop already at steep part of curve)

Management:

  1. Triple airway maneuver
    - Head tilt
    - Chin left
    - Jaw thrust
  2. Give O2 (high flow)
  3. Airway adjuncts
    - Nasopharyngeal airway / Oropharyngeal airway
  4. Suction blood, vomitus, remove FB
  5. Endotracheal intubation
    - to **bypass obstruction (e.g. vocal cord spasm)
    - can also put in catheter in ET tube for **    suction
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7
Q

Breathing: ***Hypoventilation

A

Hypoventilation
- most common cause of hypoxia

Causes

  1. Poor respiratory **drive (Blunted response to CO2 —> **TV↓)
    - Residual anaesthetic effect
    - Opioid
    - CNS problem
  2. Poor respiratory muscle function (FRC↓ ∵ muscles relaxed —> some atelectasis (small airway closure))
    - Residual anaesthetic, muscle relaxant effect —> **Residual muscle paralysis
    - Diaphragmatic splinting
    —> **    Pain —> cannot flatten diaphragm as much —> 60% ↓ in **VC after upper abdominal operations)
    —> **    External compression —> Obesity / Gastric distension (esp. when bag air into stomach) / Tight dressings
  3. ***Pulmonary disease
    - Pneumothorax (e.g. by surgery, interventions (e.g. central line insertion, upper limb brachial plexus block), COPD)
    - Severe COPD, asthma

Management:

  1. ABC
  2. Give O2 + ***Ventilation (manual / mechanical)
  3. Endotracheal intubation (if needed)
  4. Find + Treat underlying cause
  5. Consider antidote if opioid / BDZ overdose: Naloxone / Flumazenil
  6. Reverse any residual muscle relaxant effect

Opioid overdose:

  • Large doses of opioid used
  • Patient risk factors: Small, Frail elderly, Renal impairment
  • Pinpoint pupils
  • Low RR (<10/min)
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8
Q

Breathing: ***Hypoxaemia

A
  • SpO2 <90% / PaO2 <8 kpa
  • Limitations of pulse oximetry (SpO2):
    —> Poor perfusion (∵ Hypotension / Hypothermia)
    —> Motion artefacts
    —> Inaccurate at low SpO2 levels (e.g. 60-70%)
  • **Respiratory causes:
    1. Hypoventilation
    2. Atelectasis
    3. Lobar / Segmental collapse (e.g. by sputum)
    4. Aspiration (∵ cough / gag reflex impaired; esp. in patients not adequately fasted)
    5. Pulmonary edema (∵ pre-existing health condition / too much fluid given)
    6. Pneumothorax
    7. Bronchospasm / Laryngospasm (∵ pre-existing health condition / induced by airway interventions e.g. intubation, extubation)
  • **Circulatory causes:
    1. Hypotension
    2. ↓ CO
  • Metabolic causes (High metabolic demand):
    1. Fever (e.g. Malignant hyperthermia by **    anaesthetic agent / **    suxamethonium)
    2. Shivering

Management:

  1. ABC
  2. Give O2 (high flow)
  3. Find + Treat underlying cause

Evaluation:

  1. History (e.g. any vomiting) + P/E (auscultation for wheezes, reduced breath sound)
  2. Pulse oximetry
  3. ABG measurement
  4. CXR
  5. Bronchoscopy (can be therapeutic by suction)
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9
Q

Circulatory problems: ***Hypotension

A

Shock

  1. Hypovolaemic
    - Tachycardia (may not be present in elderly), ↓ Urine output, ↓ CVP
    - ***Blood loss (during surgery / rebleeding)
    - Dehydration: long fasting, fluid shift (e.g. intestinal obstruction), fever, vomiting, diarrhoea
  2. Cardiogenic
    - Myocardial ischaemia / infarction (usually a few days after post-op)
    - Arrhythmia
    - Ventricular dysfunction
    - Valvular pathology
  3. Distributive
    - ***Low SVR
    —> Drugs: Anaesthetic drugs, Anti-hypertensive
    —> Regional anaesthesia techniques: Epidural analgesia (EA), High spinal
    —> Sepsis (take time to develop)
    —> Anaphylaxis (significant portion of anaesthetic-related death but rare now)
  4. Obstructive
    - **Sudden ↓ in End-tidal CO2 (indication of **cardiac output and ***pulmonary blood flow)
    - Pneumothorax (esp. Tension)
    - Cardiac tamponade
    - Pulmonary embolism
    - Fat / Air / Amniotic fluid embolism

Evaluation:
1. BP monitor

  1. Organ perfusion
    - Brain: consciousness
    - Heart: ischaemia
    - Kidney: urine output
  2. CVP
    - central line can give drugs (e.g. high dose inotropes) / fluids
  3. A-line
    - allow continuous monitoring
  4. Echocardiogram

Management:

  1. ABC
  2. ECG + Tight BP monitoring
  3. Fluid resuscitation (e.g. colloids, blood products)
  4. Vasopressors / Inotropes
  5. FInd + Treat underlying cause
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10
Q

Circulatory problems: ***Hypertension

A
  • SBP >180 mmHg, DBP >100 mmHg
  • 20% more than baseline
  • Undesirable ∵ ↑ risk of CVS morbidity e.g. stroke, MI

Causes:

  1. ***Pain
  2. Discomfort (e.g. Foley, full bladder, bowel distension, confusion)
  3. ***Hypoxia / Hypercapnia (CO2 stimulate sympathetic system)
  4. Iatrogenic (e.g. inotropes)
  5. ***Metabolic (e.g. Thyroid storm, Malignant hyperthermia)
  6. ↑ICP
  7. Pre-existing hypertension

Management:

  1. ABC
  2. Exclude + Treat pain
  3. Exclude other discomfort
  4. Rule out sinister causes
  5. Drug therapy
    - **Beta blockers
    - **    GTN
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11
Q

Circulatory problems: ***Arrhythmias

A

Causes:

  1. Hypoxia / Hypercapnia
  2. Electrolyte / Acid-base disturbances (esp. during intra-op period ∵ fluid shifts)
  3. Myocardial ischaemia
  4. Fever / Hypothermia
  5. Pre-existing heart disease
  6. Pain / Anxiety
  7. Endocrine disorders
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12
Q

Neurological problem: ***Post-operative delirium

A
  • Acutely altered + fluctuating mental status with inattention + altered level of consciousness
  • ↑ risk of poor outcome

Risk factors:

  • Elderly
  • Cognitive impairment
  • Vascular surgery
  • Hip fracture surgery

Causes:

  1. Pain / other discomfort
  2. Hypoxia
  3. Hypotension
  4. Cerebral hypoxia
  5. Cerebral injury (e.g. stroke)
  6. Electrolyte / Endocrine imbalances
  7. Drugs (e.g. Ketamine (analgesic but with psychomimetic effect), Drug withdrawal (e.g. long term opioid, substance abuse), Anticholinergic)

Evaluation:

  1. ABC
  2. History
  3. Neurological exam (rule out stroke)
    - Focal signs
    - GCS
  4. Electrolytes, BG, Temp
  5. CT brain
  6. Consider ***sedation if treatable cause excluded / need for imaging
  7. Anti-psychotics (e.g. ***Haloperidol)
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13
Q

Hypothermia

A
  • Core temp <35oC
  • ↑ heat loss + ↓ heat generation during GA
    (- Anaesthetic drugs itself can cause hypothermia)

Risk factors:

  • Paediatric (high SA/Vol ratio) / Elderly
  • Exposure
  • Administration of cold fluids (e.g. blood products)

Effect:

  1. CVS —> MI (∵ **vasoconstriction), **Arrhythmia (e.g. VF)
  2. **Coagulopathy —> Bleeding —> **Acidosis —> ↓ myocardial performance
  3. ***Left shift of O2 dissociation curve (Hb not releasing O2 to cells)
  4. Shivering —> ↑ O2 consumption
  5. ↓ Drug metabolism —> Prolonged drug effect
  6. ↑ Wound infection
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14
Q

Post-operative Pain

A
  • Unpleasant, poor patient satisfaction
  • Prolonged recovery + hospital stay
  • ↑ Chronic post-surgical pain (>3 months post-op)

↑ Risk of:

  1. CVS
    - Myocardial, Cerebral ischaemia
  2. Respiratory
    - Pneumonia
    - Atelectasis

Methods of Pain relief:

  • **Multimodal
    1. Systemic drugs
  • Non-opioids: Paracetamol, NSAID, Ketamine
  • Opioids (PCA, IV bolus)
  1. Regional anaesthesia / analgesia
    - Epidural (i.e. Neuraxial)
    - Peripheral nerve block / catheters (i.e. Local infiltration)
  2. Procedure-specific analgesia
    - Match analgesic to type of surgery (producing different intensity, characteristic of pain)
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15
Q

Complications of Analgesic interventions

A

General:
1. Allergy

Opioids:

  1. Sedation, Dizziness
  2. N+V, Constipation
  3. Respiratory depression (rare)

Epidural:

  1. ***Hypotension (esp. if block is at a high position)
  2. ***Respiratory depression
  3. ***Neurological impairment
  4. Infection
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16
Q

Post-operative N+V (PONV)

A
  • Common (~30-50% after GA)

Risk factors:

  1. Patient
    - **Female
    - **    Young
    - History of PONV / motion sickness
    - ***Non-smoker
    - Post-op use of opioids
  2. Anaesthetic
    - Duration
    - **Nitrous oxide
    - **    Etomidate
  3. Surgery
    - Middle ear surgery
    - ***Laparoscopic

Assessment of risk of PONV:
- ***Apfel score
—> higher score —> more anti-emetic prophylaxis needed

Management:

  1. ABC
  2. Check BP, HR
  3. ***Rule out surgical (e.g. GI obstruction) / neurological problems (e.g. ↑ ICP)
  4. Ensure adequate hydration, correct electrolyte imbalances
  5. Treat pain + anxiety
  6. Drug therapy
17
Q

Anti-emetic drugs

A
  1. Serotonin antagonist
    - **Ondansetron
    - **    Tropisetron
  2. Steroid
    - ***Dexamethasone
  3. Dopamine antagonists
    - Droperidol
    - Metoclopramide
    (- Haloperidol)
  4. Antihistamines
    - Cyclizine
  5. Anticholinergic
    - Scopolamine
    - Hyoscine hydrobromide
  6. Others
    - Propofol
    - BDZ
    - Clonidine

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